Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment

Abstract

Background In the aging society, many patients with movement disorders, pain syndromes, or psychiatric disorders who are candidates for deep brain stimulation (DBS) surgery suffer also from cardiovascular co-morbidities that require chronic antiplatelet or anticoagulation treatment. Because of a presumed increased risk of intracranial hemorrhage during or after surgery and limited knowledge about perioperative management, chronic antiplatelet or anticoagulation treatment often has been considered a relative contraindication for DBS. Here, we evaluate whether or not there is an increased risk for intracranial hemorrhage or thromboembolic complications in patients on chronic treatment (paused for surgery or bridged with subcutaneous heparin) as compared to those without. Methods Out of a series of 465 patients undergoing functional stereotactic neurosurgery, 34 patients were identified who were on chronic treatment before and after receiving DBS. In patients with antiplatelet treatment, medication was stopped in the perioperative period. In patients with vitamin K antagonists or novel oral anticoagulants (NOACs), heparin was used for bridging. All patients had postoperative stereotactic CT scans, and were followed up for 1 year after surgery. Results In patients on chronic antiplatelet or anticoagulation treatment, intracranial hemorrhage occurred in 2/34 (5.9%) DBS surgeries, whereas the rate of intracranial hemorrhage was 15/431 (3.5%) in those without, which was statistically not significant. Implantable pulse generator pocket hematomas were seen in 2/34 (5.9%) surgeries in patients on chronic treatment and in 4/426 (0.9%) without. There were only 2 instances of thromboembolic complications which both occurred in patients without chronic treatment. There were no hemorrhagic complications during follow-up for 1 year. Conclusions DBS surgery in patients on chronic antiplatelet or anticoagulation treatment is feasible. Also, there was no increased risk of hemorrhage in the first year of follow-up after DBS surgery. Appropriate patient selection and standardized perioperative management are necessary to reduce the risk of intracranial hemorrhage and thromboembolic complications.

Do Antibiotic-Impregnated Envelopes Prevent Deep Brain Stimulation Implantable Pulse Generator Infections? A Prospective Cohort Study

“…Peri-operative antibiotic use is strongly associated with lower infection rate [ 6 ] and may have contributed to the relatively low infection rate in this study. Given the low infection rate, our study did not confirm potential risk factors reported in retrospective series including primary [ 7 ] or repeat implantation [ 8 ], operation time, body mass index, age, sex, diabetes [ 9 ], smoking, indication, capsulotomy, post-operative ICU admission [ 10 ], anti-thrombotic medication use [ 11 ], antibiotic wash, chlorhexidine skin preparation [ 12 ] (20), topical vancomycin powder [ 13 ], glycerol [ 14 ], or preoperative MRSA screening and treatment [ 15 ].…”

“…However, there was a low haematoma rate in our series (2/427), similar to the rate of 0.4% in the WRAP-IT trial. A recent publication indicated a 1% haematoma rate for patients not on anti-thrombotic medication and a 5.9% haematoma rate for patients taking anti-thrombotic medication [ 11 ]. With increasing use of anti-thrombotic medication, there may be a role for assessing envelope use in this higher risk population.…”

Intracranial Bleeding in Deep Brain Stimulation Surgery: A Systematic Review and Meta-Analysis

“…All of the descriptive analyses were performed using the built-in Microsoft Excel functions [32]. The meta-analysis and meta-regression were performed via OpenMeta [Analyst], an open-source cross-platform software [33].…”

Intravenous thrombolysis and mechanical recanalization for acute ischemic stroke in deep brain stimulation patients: a case series

“…In addition, in the early postoperative phase (up to 72 h after surgery), hemorrhages may be leveraged by blood pressure derailments. Treatment recommendations include restarting of oral anticoagulation or antiplatelet therapy 14–28 days after DBS surgery [ 12 ] if necessary for comorbidities, reflecting normalization of the general postoperative bleeding risk after this period.…”